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NOTIFICATION OF INTENT TO PROVIDE
HOME INSTRUCTION FOR SCHOOL YEAR 20 ___-___
(Pursuant to NRS 392.070 & NAC 392.015 through 392.075)

Parent/Guardian: _____________________________________________________

Address: ____________________________________________________________

City, State, Zip code: ___________________________________________________

Phone: ______________________________________________________________

Student(s): (List only the names of the children for whom you are seeking an exemption.)
 

Name (Full Name)         
Birth date
Grade
Last School Attended
       
       
       
       
       
       
       

Site where schooling will take place:
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
 

1. INSTRUCTOR: (check one)

__ Option A Parent has previously home schooled and is requesting an exemption for another year
     and/or another child with a waiver of other option requirements.

Year(s) home schooled ____________ District/State _________________________

__ Option B Parent does the teaching and textbook selection with the help of a consultant.
     Instruction by the parent with consultation from another home educator who has three or more
     years of experience home schooling at the same level (elementary/secondary) as the student, or is a
     teacher who is licensed by the State of Nevada to teach the grade level of the student. This
     requirement is for the first year only.

Name of consultant: ___________________________________________________

__  Option C Parent qualifies for a license to teach. Instruction from the child’s parent if the parent
     qualifies for a teaching license in any state to teach the grade of the child. The parent will need to
     demonstrate that he/she has the necessary credentials to qualify for a teaching license.

__________________________________________________
(name)

__________________________________________________
(license number)

_________________________________
(expiration date)

__ Option D Parent enrolls child in an “approved correspondence program.” Instruction by the
     parent when the child is enrolled in an approved correspondence program. A correspondence
     program is approved when it is provided by: (a) a nationally or regionally accredited association
     recognized by the Secretary of Education and accredited for elementary and secondary education,
     (b) a public school in Nevada offering correspondence study at the elementary and secondary level,
     or both, or (c) a private correspondence school licensed by the State Board of Education (a listing of
     approved correspondence programs is available from the State Department of Education).

__ Option E Parent hires a licensed teacher to teach child(ren). Instruction by a teacher, other than
     the parent, who possesses a teaching license in the State of Nevada to teach the grade level of the
     child.

________________________________________________
(name of licensed teacher)

________________________________________________
(license number)

_____________________________________
(expiration date)

_____________________________________________
(grade levels licensed to teach/endorsements)

_____________________________________________
(teacher’s signature)

2. PROPOSED EDUCATIONAL GOALS:

Do this separately for each child listed on the front page. List your goals in each subject area by briefly
describing what you want the student to have learned by the end of the year. You may use (or
photocopy) the index of your chosen textbooks, the Nevada State Department of Education Curriculum
Guide, your school district goals and objectives, your curriculum scope and sequence guide, etc.
Remember, goals may be adjusted if listed goals are either not met or are exceeded. If desired, you may
list non-academic goals ( such as “character building”).

     We have obtained a copy of, and will use, our local district’s goals and objectives, and/or the
     Nevada State Department of Education Curriculum Guide.

     We will use our goals and objectives listed on the back of this paper, or attached with a separate
     sheet of paper.

3. THE INSTRUCTIONAL MATERIALS TO BE USED ARE:

Please make a list of any textbooks, including titles and authors, as well as any other books or materials
that you plan to use. You can list encyclopedia, educational games, computer software, musical
instruments, art supplies, science equipment, time lines, flash cards, magazine subscriptions, library
resources, or anything else your feel that you will be using during the year. Please list the materials on the
back of this paper or attach a separate sheet of paper.

4. CALENDAR OF THE SCHOOL YEAR:

Nevada administrative regulations require you to provide 180 days of instruction during the school year.
The calendar starts on July 1st and ends on June 30th. You may choose any 180 days during that time
period. You may follow your district calendar or devise your own.

     Local district calendar will be followed

     We will follow the calendar below:

MONTH & NUMBER OF DAYS

Jul _______________

Aug_______________

Sept _______________

Oct _______________

Nov _______________

Dec _______________

Jan _______________

Feb _______________

Mar _______________

Apr_______________

May_______________

Jun_______________

Total _______________ Days (remember to provide at least 180 days)
 

*******************************
I/we hereby declare that the educational plan presented in this Notification of Intent to Provide Home
Instruction will be followed, and I/we will assume full responsibility to provide equivalent instruction
to my/our child(ren).

________________________________________
Parent/Guardian

________________________________________
Parent/Guardian

______________________
Date